Kevin R. Loughlin

Plasma levels of vascular endothelial growth factor are increased in patients with metastatic prostate cancer

OBJECTIVES Vascular endothelial growth factor (VEGF) is a cytokine that plays an important role in tumor angiogenesis. VEGF is overexpressed in many human cancers, including prostate cancer, but circulating levels of VEGF in patients with prostate cancer have not been reported. In this study, we analyzed plasma concentrations of VEGF in a cohort of patients with prostate cancer and compared them with a normal population. METHODS Twenty-six healthy, cancer-free individuals and 80 patients with prostate cancer (54 patients with localized prostate cancer and 26 patients with metastatic prostate cancer [bone or lymph node positive]) were analyzed in this study. Blood was drawn in the same fashion from all individuals and deposited in tubes containing ethylenediaminetetraacetic acid as anticoagulant. Plasma was extracted and VEGF concentrations were determined using a quantitative sandwich enzyme immunoassay technique. RESULTS Median plasma VEGF was 28.5 pg/mL (interquartile range 19.3 to 57.0) in patients with metastases; 7.0 pg/mL (interquartile range 0 to 26.5) in patients with localized disease, and 0 pg/mL (interquartile range 0 to 24) in controls. These differences were statistically significant (P <0.001). When compared group by group, the metastatic group had significantly higher plasma VEGF than the localized disease group and the control group (P = 0.003 and P <0.001, respectively). There was a tendency for plasma VEGF to be higher in the localized disease group than in the control group, a trend that almost reached statistical significance (P = 0.038). Using a cutoff of 18 pg/mL, the sensitivity and specificity of the test in differentiating between patients with and without metastatic disease was 81% and 71%, respectively. The odds of metastatic disease were almost 10 times greater for patients with VEGF values greater than 18 pg/mL than for those with values less than 18 pg/mL. There was no correlation between age and plasma VEGF values or between plasma VEGF and serum prostate-specific antigen (PSA). However, patients with serum PSA greater than 20 ng/mL had significantly higher plasma VEGF values than patients with serum PSA less than 20 ng/mL (P <0.001). No direct relation was found between Gleason sum and plasma VEGF, although VEGF levels were higher in patients with Gleason sums of 8 to 10 than in patients with lower Gleason sums. CONCLUSIONS Our study indicates that patients with metastatic prostate cancer have higher plasma VEGF levels than patients with localized disease or healthy controls. A larger prospective study is needed to confirm the predictive utility of VEGF.

Spiral Computerized Tomography in the Evaluation of Acute Flank Pain: A Replacement for Excretory Urography

PURPOSE We determined the value of noncontrast enhanced spiral computerized tomography (CT) in the evaluation of suspected renal colic. MATERIALS AND METHODS Thin section (5 mm.) noncontrast enhanced CT was used to evaluate 100 patients presenting to the emergency room with flank pain. The 55 patients with ureteral obstruction were followed at the urology outpatient clinic and by telephone interview, while 45 without ureteral obstruction were followed by telephone interview and chart review. Sensitivity, specificity, and positive and negative predictive values for CT were determined, with passage, retrieval or identification of a stone on a retrograde study considered the gold standard for diagnosis. RESULTS A total of 89 patients had adequate clinical followup to assess outcome accurately. Of 55 patients with ureteral obstruction on CT 11 underwent endoscopic stone removal, while 44 were treated conservatively with stone passage documented in 39. Of the 45 patients without ureteral stones identified 38 did not pass calculi and CT provided a definite diagnosis in 14. There was 1 false-negative study. The results yielded 98% sensitivity, 100% specificity, and 100% positive and 97% negative predictive values. CONCLUSIONS Noncontrast enhanced spiral CT was accurate and reliable in detecting obstructing ureteral calculi in patients with flank pain.

No-Incision Pubovaginal Suspension for Stress Incontinence

We describe a modified needle suspension for urinary incontinence that eliminates all incisions. The anterior vaginal wall is suspended from the rectus fascia with 2 heavy nonabsorbable monofilament mattress sutures. The sutures pass down through and back up through the full thickness of the vaginal wall, and are tied suprapubically to bury the knot into the fat in the suprapubic puncture site. The technique is based on our laboratory observation that in rats and guinea pigs monofilament mattress sutures that are tied under tension to include the outside abdominal skin will cut through the skin, and become internalized and accepted without any residual inflammation if the knot is buried initially. The simplified technique makes routine use of outpatient surgery and allows for the use of local anesthesia only in selected patients. At 2 1/2 years the continence rate in the first 38 patients exceeded 87 per cent. There were no failures among the last 14 patients after the technique was modified to include an extra full thickness pass of the mattress suture through the vaginal wall. There have been no significant complications.

Complications of Laparoscopic Pelvic Lymph Node Dissection

Intraoperative and postoperative complications were assessed in the first 372 patients undergoing laparoscopic pelvic lymph node dissection at 8 medical centers. In 16 patients laparoscopic node dissection could not be completed due to patient body habitus or technical difficulties. Of these aborted procedures 14 occurred during the initial 8 dissections at each institution. A total of 55 complications (15%) occurred: 14 were noted in the intraoperative and 41 in the postoperative period. Of these patients 13 required open surgical intervention for the treatment of a complication. Complications included vascular injury (11 patients), viscus injury (8), genitourinary problems (10), functional/mechanical bowel obstruction (7), lower extremity deep venous thrombosis (5), infection/wound problem (5), lymphedema (5), anesthetic complications (2) and obturator nerve palsy (2). Based on our experience, there is a significant learning curve associated with performing laparoscopic pelvic node dissection. However, with experience and adherence to laparoscopic surgical principles, the risk of complications may be minimized.

DAZ Family Proteins Exist Throughout Male Germ Cell Development and Transit from Nucleus to Cytoplasm at Meiosis in Humans and Mice

Abstract The human DAZ gene family is expressed in germ cells and consists of a cluster of nearly identical DAZ (deleted in azoospermia) genes on the Y chromosome and an autosomal homolog, DAZL (DAZ-like). Only the autosomal gene is found in mice. Y-chromosome deletions that encompass the DAZ genes are a common cause of spermatogenic failure in men, and autosomal homologs of DAZ are essential for testicular germ cell development in mice and Drosophila. Previous studies have reported that mouse DAZL protein is strictly cytoplasmic and that human DAZ protein is restricted to postmeiotic cells. By contrast, we report here that human DAZ and human and mouse DAZL proteins are present in both the nuclei and cytoplasm of fetal gonocytes and in spermatogonial nuclei. The proteins relocate to the cytoplasm during male meiosis. Further observations using human tissues indicate that, unlike DAZ, human DAZL protein persists in spermatids and even spermatozoa. These results, combined with findings in diverse species, suggest that DAZ family proteins function in multiple cellular compartments at multiple points in male germ cell development. They may act during meiosis and much earlier, when spermatogonial stem cell populations are established.

Prevalence and clinical features of HTLV neurologic disease in the HTLV Outcomes Study

Background: Almost 20 years after its discovery, the prevalence and clinical course of human T-lymphotropic virus type I (HTLV-I)–associated myelopathy (HAM, also known as tropical spastic paraparesis [TSP]) remain poorly defined. Whereas the causative association of HTLV-I and HAM/TSP is generally recognized, controversy still surrounds the relationship between HTLV-II and HAM/TSP. Methods: The HTLV Outcomes Study (HOST—formerly Retrovirus Epidemiology Donor Study [REDS]) is a prospective cohort study including 160 patients with HTLV-I, 405 patients with HTLV-II, and 799 uninfected controls who have been followed every 2 years since 1990–1992. Clinical outcomes are measured by health interviews and examinations, and blood samples are obtained. Results: Six cases of HTLV-I–associated myelopathy (3.7%, 95% CI 1.4 to 8.0) and four cases of HTLV-II myelopathy (1.0%, 95% CI 0.3 to 2.5) have been diagnosed since the formation of the cohort. There have been no cases of HAM/TSP diagnosed among HTLV-negative subjects (0.0%, 95% CI 0.0 to 0.5). Clinical features of the cases include lower extremity hyperreflexia, variably associated with weakness, spasticity, and bladder dysfunction. Conclusions: Systematic screening of HTLV-infected blood donors reveals a high prevalence of HAM/TSP. The clinical course of HAM/TSP appears highly variable. HTLV-II–associated myelopathy generally presents with milder and more slowly progressive signs and symptoms.

Relationship of Sperm Parameters with Levels of Reactive Oxygen Species in Semen Specimens

The levels of reactive oxygen species were compared in semen specimens from suspected subfertile men and from normal volunteers, and correlated with other semen parameters. Reactive oxygen species formation was measured in semen samples that had no white blood cells by a chemiluminescence assay with a Luminometer. The relationship of seminal reactive oxygen species to several sperm parameters was evaluated. A total of 84 specimens from 69 suspected subfertile men and 15 normal volunteers was tested for reactive oxygen species production. Comparison of reactive oxygen species levels in white blood cell-negative patient and donor specimens showed significantly higher values (p < 0.005) in the patient group. Similarly, levels in patient and donor specimens with normal sperm motility were significantly lower (p < 0.005) than those in specimens showing poor motility. The seminal reactive oxygen species levels of white blood cell-negative patients with abnormal morphology were significantly higher (p < 0.005) than those in white blood cell-negative patients with normal morphology. Our results show that seminal reactive oxygen species levels in suspected subfertile men are significantly higher than in normal men, and that the presence of excess reactive oxygen species in semen is positively correlated with low sperm concentration, poor motility and poor morphology. In conclusion, the evaluation of reactive oxygen species levels in cases of idiopathic male infertility could serve as an important marker of sperm dysfunction.

Reactive oxygen species generation by seminal cells during cryopreservation

OBJECTIVES To test the hypothesis that conventionally used procedures for semen cryopreservation may cause an increase in the production of reactive oxygen species (ROS) by sperm or by seminal leukocytes, which may contribute to poor sperm function following cryopreservation. METHODS Eighteen semen specimens with normal parameters from healthy male donors 22 to 40 years of age were each divided into two portions. The first portion was combined 1:1 with Test Yolk Buffer-Glycerol Freezing Medium and was frozen by gradual cooling into liquid nitrogen (-196 degrees C). The second portion was washed and the cells were resuspended in Sperm Washing Medium (SWM) and incubated at room temperature to serve as controls. After a period of treatment, frozen samples were thawed and semen cells were washed and resuspended in SWM. ROS generation by semen cells from each treatment group was measured on a luminometer. Sperm motility, sperm viability, and sperm membrane integrity were also measured in both control and freeze-thaw samples. To further assess ROS generation by semen cells during the cooling process, aliquots of washed semen cells and purified polymorphonuclear leukocytes (PMNs) were incubated separately at different temperature conditions (37 degrees C, 22 degrees C, 4 degrees C, and -20 degrees C). ROS activity in each treatment group was measured and compared with each other. RESULTS In both semen cells and PMNs, ROS activity increased significantly during the cooling process. The highest ROS levels were recorded in both groups when cooled to 4 degrees C. The ROS levels were extremely low in samples cooled to -20 degrees C and in freeze-thaw samples, probably due to marked loss of cell viability. CONCLUSIONS Gradual reduction of temperature during the process of semen cryopreservation can cause a significant ROS generation by semen cells. ROS is particularly elevated during cooling if the semen sample is contaminated by more than 0.5 x 10(6) leukocytes. Removal of leukocytes from semen samples or treatment with antioxidants prior to cryopreservation may improve sperm viability and function.

Tumor-Specific Urinary Matrix Metalloproteinase Fingerprinting: Identification of High Molecular Weight Urinary Matrix Metalloproteinase Species

Purpose: We have previously reported that matrix metalloproteinases MMP-2, MMP-9, and the complex MMP-9/NGAL can be detected in urine of patients with a variety of cancers including prostate and bladder carcinoma. In addition, we also detected several unidentified urinary gelatinase activities with molecular weights >125 kDa. The objective of the current study was to identify these high molecular weight (HMW) species, determine their potential as predictors of disease status, and ask whether a tumor-specific pattern existed based on urinary MMP analysis. Experimental Design: Chromatography, zymography, and mass spectrometry was used to identify HMW gelatinase species of ∼140, 190, and >220 kDa in urine of cancer patients. To determine whether a tumor-specific pattern of appearance existed among the MMPs detected, we analyzed the urine of 189 patients with prostate or bladder cancer and controls. Results: The ∼140, >220 kDa, and ∼190 HMW gelatinase species were identified as MMP-9/tissue inhibitor of metalloproteinase 1 complex, MMP-9 dimer, and ADAMTS-7, respectively. The frequency of detection of any MMP species was significantly higher in urine from prostate and bladder cancer groups than controls. MMP-9 dimer and MMP-9 were independent predictors for distinguishing between patients with prostate and bladder cancer (P < 0.001 for each) by multivariable analysis. Conclusions: This study is the first to identify a tumor-specific urinary MMP fingerprint that may noninvasively facilitate identification of cancer presence and type. This information may be of diagnostic and prognostic value in the detection and/or clinical monitoring of disease progression and therapeutic efficacy in patients with bladder or prostate cancer.

Partial nephrectomy: alternative treatment for selected patients with renal cell carcinoma

OBJECTIVES To analyze the experience and the results of partial nephrectomy in a single institution over the last 10 years in order to optimize patient selection and minimize morbidity. METHODS This is a retrospective chart review of 64 patients (mean age 56.6 years, range 18 to 88; 43 men, 21 women) who underwent 66 partial nephrectomies at the Brigham and Womens Hospital between 1987 and 1997. Preoperatively, 62% of the patients had no symptoms, whereas 38% had pain and/or hematuria. The indications were elective in 23 patients, solitary kidney in 28 (14 with bilateral asynchronous tumor), bilateral synchronous tumor in 7, von Hippel-Lindau disease with normal contralateral kidney in 3, lymphoma in 3, and other indications in 2 patients. Surgery was performed for solid or indeterminate renal mass suspected of being renal cell carcinoma in 58 patients. RESULTS The most common final pathologic diagnosis was renal cell carcinoma in 47 procedures. One or more complications occurred after 18 procedures (15 with solitary kidney and 3 in patients with normal contralateral kidney) or 27% of the patients. The most common complication was an increased creatinine level (two times the baseline), occurring in 10 procedures (15.1%). Transfusion was necessary in 37 of 66 procedures (56%), and the mean blood loss was 836 cc (range 100 to 3200). Regarding renal function, 85% of the patients had a minimal increase in creatinine of less than 0.5 mg/dL after surgery (all patients with a normal contralateral kidney are in this group); 3 patients required either temporary (n = 1) or permanent (n = 2) dialysis. Other complications are also described. The mean length of stay among 65 patients was 6.5 days (range 3 to 14). The differences between length of stay, blood loss, and tumor size were statistically significant between the solitary kidney group and the elective indications group (P < 0.001). CONCLUSIONS Nephron sparing surgery is feasible and relatively safe in patients with a normal contralateral kidney. Awareness of potential complications should aid in the selection of appropriate patients for this procedure.